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it time to ditch this fixation?Martin Livingston MD, FRCPsych
Professor Cunningham Owens, in his paper com- cacy. The differences between drugs usually lie in side-
paring older and newer antipsychotics in this issue
effect profiles, often the key factor in drug selection.
(Antipsychotics: is it time to end the generation game?,
see pages 48–50), has drawn several important conclu-
Wonderland may, however, be tilting at windmills in his
sions that should influence our prescribing. Classifying
recommendation for thorough dose-ranging studies of
antipsychotics as ‘atypical’ or ‘typical’ is unhelpful.
the older drugs to be carried out so that we are better
The evidence supporting such a dichotomy is lacking,
informed on what is the minimum effective dose. There
despite the fact that the BNF sets out these drugs in
is little commercial benefit for the pharmaceutical com-
panies in re-examining older patent-expired drugs where
The term ‘atypical’ does not define a group of
there is unlikely to be a new prescribing indication.
antipsychotics that are more effective in any symptom
domain in schizophrenia than a previous generation
Using the whole range
of such drugs. All antipsychotics, with the notable
This iconoclastic paper does carr y a positive message,
exception of clozapine, have approximately equal effi-
which is that we should feel free to use the whole range
of antipsychotics, targeting the drug therapy to the
done – quetiapine (Seroquel) or aripiprazole are use-
patient’s clinical needs and tolerance.
ful choices, the latter drug also being an appropriate
The malnourished schizophrenic may benefit from
choice in Parkinson’s disorder where there are psy-
some weight gain, so olanzapine and chlorpromazine
would be good choices here. If obesity is a problem,
For the poor responder with schizophrenia who has
or the metabolic syndrome is developing, then arip-
failed to improve significantly on two consecutive
iprazole (Abilify) and haloperidol would be helpful.
antipsychotics, a trial of clozapine is indicated. This is a
If poor adherence is evident in an outpatient with
drug to be avoided – at least in higher doses – in patients
psychosis, super vised administration of an oral drug
with epilepsy but trifluoperazine, haloperidol or
becomes feasible when prescribing pimozide (Orap),
sulpiride are antipsychotics less likely to provoke seizures.
which can be given as infrequently as three times per
Similarly, the revival of interest in long-acting
week due to its long half-life. Is a once-daily regimen
injectable antipsychotics need not be confined to
sought? Choose aripiprazole, haloperidol or olanzapine.
newer compounds. Older drugs such as flupentixol
If the patient has hyperprolactinaemia and com-
(Depixol), zuclopenthixol (Clopixol), fluphenazine
plains of galactorrhoea or amenorrhoea, avoid risperi-
and haloperidol (Haldol Decanoate) in their respec-
tive ‘depot’ formulations are as effective as the newer
While we await the emergence of new antipsy-
formulations and may be well tolerated, especially if
chotics that do not rely on the dopamine model of psy-
chosis, the lack of which Cunningham Owens laments,
The depots are, however, not good choices in renal
we should take advantage of all the available options
or hepatic impairment. Aripiprazole and trifluoper-
azine are appropriate drugs in the former, and haloperi-
dol is the leading choice in hepatic impairment.
Declaration of interests
Dr Livingston has ser ved on an advisor y board for
paliperidone on behalf of Janssen-Cilag and he has
Early inter vention in psychosis ser vices, which tend to
also received speaker fees for chairing meetings spon-
use the newer drugs as first choice, may wish to take a
fresh look at the array of compounds that become
available once the fixation with atypicality is aban-
Dr Livingston is consultant psychiatrist and honorar y
doned. Again, care with dosage, usually involving slow
senior clinical lecturer, Southern General Hospital,
upward titration, is the key to tolerability.
Dr. Nicholas Bodor is a Graduate Research Professor Emeritus (active) at the University of Florida College of Pharmacy, Gainesville. He joined the university in 1979 as Professor and Chairman of the Medicinal Chemistry Department, and was promoted to Graduate Research Professor in 1983. He is the Executive Director of the college’s Center for Drug Discovery,
Ganzheitliche homöopathische Therapie der ErkältungskrankheitenDie Modulare Immun-ResonanztherapieIn der Offizin haben homöopathische Komplexmittel einen hohen nähert, muss man nahezu zwingend die Stel enwert, unter anderem auch bei der Behandlung der Erkältungs-Selye berücksichtigen. Banale Infekte, ein krankheiten. Oft stehen Patienten mit einem konkreten Präparate- leichter Schnupf